Direct Deposit Agreement Form

Direct Deposit Agreement Form
I hereby authorize Divine Professional Tax Servicesto initiate a one-time automatic deposit to my account at the financial Institution named below.

Further, I agree not to holdDivine Professional Tax Services responsible for any

delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account.
Name of Financial Institution
Routing Number
Authorized Primary Printed Name
Authorized Primary Signature

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Authorized Joint Printed Name
Authorized Joint Signature

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Date

MonthDayYear
Date
Should be Empty: